Annual Financial Statements 1995 and 1996: St. Luke’s and St. Anne’s Hospital.

Mr. N. Jermyn (Chief Executive Officer, St. Luke’s and St. Anne’s Hospital) called and examined.

Acting Chairman

We resume with No. 8 - St. Luke's and St. Anne's Hospital, Annual Financial Statements 1995 and 1996. The relevant documentation has been circulated. There was correspondence dated 25 April 2000 from the hospital regarding the 1997 and 1998 accounts and correspondence dated 23 May 2000 from the Department of Health and Children regarding the same accounts. I would like to draw the attention of witnesses to the fact that they do not enjoy absolute privilege and that as and from 2 August 1998 section 10 of the Committees of the Houses of the Oireachtas (Comparability, Privilege and Immunity of Witnesses) Act, 1997, grants certain rights to persons who are identified in the course of the committee's proceedings. I welcome Mr. Nicholas Jermyn, chief executive officer, and I ask him to introduce his colleague.

Mr. Jermyn

I am accompanied by Mr. Donal Kelly, general manager of St. Luke's and St. Anne's Hospital.

Acting Chairman

Another official from the Department of Health and Children is present.

Ms Fiona Prendergast

I am Fiona Prendergast from the finance unit, working on the voluntary hospital side.

Acting Chairman

You are more than welcome, Ms Prendergast I ask the Comptroller and Auditor General to comment on the accounts.

Mr. Purcell

Thank you, Acting Chairman. The accounts of St. Luke's and St. Anne's Hospital, as it was then known, first came under the remit of the committee in 1994 and the accounts for that year were examined by the committee at its meeting on 20 June 1996. The accounts for 1995 and 1996 only are before the committee today. Although the accounts for 1997 and 1998 have been audited and cleared by my office, they have not been signed by the board of the hospital so I am not in a position to append my audit report to them. There is nothing untoward about that in a regularity sense. The delay in adopting the accounts arises from the fact that there was no board in place from July 1998 until one was appointed earlier this year. During that time changes in the way the hospital was constituted were being put in place and this required things like establishment orders. In effect St. Anne's was being subsumed into St. Luke's and the voluntary religious order which ran St. Anne's was getting out of that particular business. The complete position is explained by the chief executive in a letter to the committee. The Department of Health and Children has also recently furnished the committee with a letter explaining the situation.

Getting back to the 1995 and 1996 accounts the committee will see that in the audit reports for both years I refer to the lack of complete registers of fixed assets, which seems to be a recurring theme. As you know, there have been problems in the health boards also in this regard. In those situations it makes it hard to be confident that proper control is being exercised over these assets and equipment in particular. The fact that in recent years there has been an extensive capital development programme at the hospital involving construction and the installation of expensive equipment makes it all the more important that the matter is addressed sooner rather than later. In my report on the 1995 accounts I expressed dissatisfaction with the level of control over pharmacy stocks but in the interim there has been significant improvement in this area and it is not a matter of current concern.

Acting Chairman

I appreciate Mr. Jermyn that you will be jumping from a historical perspective to a modern one but I am sure you will answer all questions. Would you like to make an opening statement?

Mr. Jermyn

No, Acting Chairman, the board issue has been covered in Mr. Michael Kelly, the Secretary General's, letter to the Committee. I have nothing further to say on the issue.

Acting Chairman

Thank you. Deputy Gildea will open the examination.

How is Mr. Jermyn dealing with the register of fixed assets now?

Mr. Jermyn

Basically, as Mr. Purcell indicated, there has been major capital investment in St. Luke's and St. Anne's Hospital, which is now known as St. Luke's Hospital. We have also at this point with the completion of our development put in place comprehensive asset register management system for the equipment. We are obviously dovetailing that in to maintenance of equipment. Over the last year, particularly going into the millennium, we had reason to bring all assets over £3,000 in.

The one issue I wish to make reference to before the committee is the type of equipment we have in St. Luke's. One piece of equipment, for example, could cost in excess of £1 million. There are expensive linear accelerators. It is not like a general hospital where lots of equipment lies around. We have six or seven main pieces of equipment in the hospital. Everything is integrated. Basically, I am satisfied as chief executive officer now that we are improving our asset register all the time. Everything over £3,000 is recorded in a equipment management system and it is being dovetailed back into the accounts. We still have some work to improve it but it is greatly improved compared to what it was, referring back to the earlier years.

Given the development that has taken place and the raising of standards, what is that status of the hospital's waiting list?

Mr. Jermyn

To answer the question, if the committee could bear with me, we do nothave what we call a waiting list for radiotherapy. We have outreach clinics spread over the country, more than 26. We have patients referred to those clinics who are then referred in to the hospital for treatment. Every patient referred in through those outreach clinicsgets an appointment time to come into the hospital.

I will be up front with the committee. Some treatments that are complex can take up to five or six weeks to plan for the person before he or she comes in for hospital treatment but at this point we have for that complex area of treatment - there is only a small group of patients for whom there is a delay - a planning stage of treatment. They receive medical care but they wait five or six weeks to be admitted to hospital. There is no waiting time for emergency admissions. I can forward details to the committee which will outline that.

Is there much of a wait for outreach clinics?

Mr. Jermyn

My understanding is that this was brought up at one of the health board meetings. We are not aware of anybody waiting to get an appointment at an outreach clinic. How it works is that the general hospital in the region, we accept referrals to the outreach clinics on the basis of a medical person referring them or a GP, who has proven histology or pathology to show that there is a possibility of cancer. If they do not get the next clinic, it is within about two or three weeks, but most patients are referred to the next clinic in the region and they are run every two weeks.

I know that the hospital has a high rate of bed occupancy. What is it?

Mr. Jermyn

The bed occupancy for St. Luke's and St. Anne's Hospital is basically as soon as a patient is out we get a patient in. It is almost 100% but it is running at 95%. In Europe, hospitals recommend about 85% occupancy. Our rate is very high. We have another facility which we call the lodge which has 100% occupancy, Monday to Friday, whereby patients sleep in the lodge. It is not like an in-patient bed.

Not with any particular reference to Mr. Jermyn but we hear about the norms in Europe, Britain and here. I would hope we could set our own standards.

Mr. Jermyn

Yes.

They would be more in tune with higher rather than lower standards. Matters have changed in recent years for our next door neighbour who had produced a higher standard in that area. What about staff adequacy and the availability of staff at administrative, medical and surgical levels?

Mr. Jermyn

As you have heard from health boards in Dublin, we have some difficulties in recruiting, particularly in the nursing area. We are a specialised hospital and obviously nurses must be highly skilled, with diplomas in oncology, etc. We are having difficulties recruiting nursing staff for St. Luke's, as well as clerical staff and, particularly, porters and catering staff. Staff are leaving to live outside Dublin and this is due mainly to the cost of housing.

What about consultancy posts?

Mr. Jermyn

At the moment we have four whole-time equivalent consultants in full-time employment. We have another two long-term locums. We are in the process of advertising for the filling of those posts and another two new posts. We are hoping to have those two new posts in the next year to year and a half on top of the six consultants we already have.

Has six been the norm in the last couple of years?

Mr. Jermyn

Yes, it would. The number of consultants in St. Luke's and St. Anne's Hospitals has not changed dramatically. With the Minister setting up this new radiotherapy special committee, in the next few years there will be a recognition that we need more radiotherapists in the country. As you know, the number of oncologists has increased but the consultant-radiotherapy ratios in this country will be increased in the coming years. There are plans in St. Luke's for another two posts within the next year and then hopefully another two posts.

On a matter which relates to administration and costs, what emphasis is placed on the importance of the national cancer register, with which Mr. Jermyn obviously co-operates? How does it determine trends in areas and regions? I put down a series of questions in the House recently relating to the incidence of cancer in various regions. Oddly enough, the incidence in many regions seems to be dropping. I presume the information is accurate but the last information I received shows that in some areas the incidence of cancer had dropped by about 10% in the past ten or 15 years.

Mr. Jermyn

St. Luke's Hospital new board, with the medical staff, has looked at the new cancers on the register. I would not like to comment on the accuracy of the register, which would be for another body to look at, but we look at the trends of new cancers reported, the number who should receive radiotherapy and then we try to project the need for radiotherapy in the country. There is a need to use the register, which is important. I take Deputy Durkan's point but I would not comment on the accuracy or otherwise of that register. I could not comment on any decrease. My information is that cancer is being detected more quickly now and I thought the figures would have gone up.

The reverse would seem to be the case. In relation to feeding information into that register, through the completion of various forms which come from various regions, to what extent does St. Luke's have an ongoing interest in that for its own information?

Mr. Jermyn

We have a great interest in that. The head of the cancer register - the chief executive - and a number of others visit our hospital and we work closely with the people collecting the data. They come to our hospital and we provide data for them. We depend on the register for looking at norms and trends but we have our own database where we look at the number of new cancers being referred to our hospital and do comparisons. It is an important working relationship.

In terms of efficiency of operation and delivery of high quality service to the public, has St. Luke's ever merged information and compared data with a similar hospital of similar size in a different country?

Mr. Jermyn

We are the main radiotherapy centre in the country, except for Cork and obviously Galway, Limerick and others will come on board later. We have linked with our colleagues in the North, the Marsden Hospital in London and we will link with some Dutch hospitals to look at quality initiatives in radiotherapy, including quality outcome, instances of risk, etc., to see how we are doing compared to other hospitals. We do some benchmarking and we are developing that. On a national level, I am not involved with looking at the incidence of cancer but it is being looked at through the Department of Health and Children, the cancer forum and other forums established at the request of the Minister to look at the incidence of cancer and the need for services.

To what extent does St. Luke's and the hospitals with whom it has a relationship, draw on information from the respective communities? Does it compare like with like or otherwise as the case may be? I am trying to get information on research and back-up information which is important in all areas of medicine but particularly this one.

Mr. Jermyn

We have a special research unit, St. Luke's Research Institute, and our medical staff, involving not only radiotherapists but pathologists and radiologists. We have many research interests and we link up with hospitals in Ireland and internationally. If the committee wishes, I can send it details of the type of research and link-ups we undertake relating to change of medical practice and the best practice.

Acting Chairman

That is important and we will avail of that offer. I note from the previous examination in 1996 that a problem arose from overpayment to some staff. One of the primary reasons given for this was the breakdown of equipment which affected the waiting list and the staff. Mr. Jermyn said at that time that staff radiologists were idle because of the breakdown. Has that been dealt with and rectified?

Mr. Jermyn

At that time, there was a certain method of payment to therapeutic radiographers. That was before the investment in capital and given the hi-tech equipment, there were many breakdowns and a need to run the machines to get better value. The staff worked what was called emergency on-call. Unfortunately, that system has not changed on a national level but a radiography working group has been established. I have been to the Labour Court and I am consistently in negotiation with the unions to look at that method of payment. Even with the investment in new equipment, we are still running out of hours to get the maximum benefit from the equipment but also because we have more new cancer referrals.

With the development of the technology we have in the hospital, we are able to treat more cancers with radiation. In the past two to five years, it has been recognised that we can give a much higher dosage of radiation to patients with certain types of tumours who will benefit. The equipment has improved and we can target the tumour with radiation. In the past, without this modern technology, we were unable to guarantee target volumes. We can now treat many more people and many more cancers, either therapeutically or palliatively. It has been recognised that with chemotherapy and radiation, in the next number of years we will see the development and need for radiotherapy services. We had addressed the issue but with the development of technology we are still in that situation.

Acting Chairman

You say you are running out of hours. I presume that is creating a waiting list. Do you still have some equipment idle at times because of the disagreement about——

Mr. Jermyn

No, it is not that we have equipment idle. I had just taken over in the hospital when it came before the Committee of Public Accounts. We had situations where we had to take machines down to maintain them. We have changed the whole system of preventative maintenance so that, for 95% of the running time, the machines are running. There was a great deal of unplanned maintenance or planned maintenance during working hours. We have moved a great deal of that out but also, with new equipment, we do not have the amount of what I call required maintenance or unplanned maintenance where machines break down. Machines were never idle. What happened was the machines were either breaking down or they needed much more maintenance because they were old. Now with the new equipment, the amount of maintenance requirement is not as high and it can also be planned.

Acting Chairman

What do you anticipate as the next stage? We have various machines and I have been pleasantly surprised by the level of change and the improvements. Where do you see it going?

Mr. Jermyn

We have prepared papers and it could be useful if I send them on. As an example, there was a great deal of brain tumours which could not be treated before because they involved what is called stereotactic treatment. We have just bought a new machine and commissioned it with the neurosurgical unit in Beaumont Hospital. We used to have to send our patients abroad. We will now be able to treat a great deal of tumours in the brain which we could not treat before because of the complexity and the ability to target with technology and computerisation. The developments will be that, with this new technology, we will be able to target tumours we could not get to before with radiation. The main development will be that, because of the technology development, we will be treating a great deal more cancerous tumours that may not have been treatable in the past.

Acting Chairman

Do we still need to send any patients abroad? I refer to the national position rather than that of the hospital.

Mr. Jermyn

There are some patients with a condition of a complex nature and, given the experience in Europe and in England and the fact that we are developing our experience here, their numbers would not justify their treatment here. There are very few patients now whom we would have to send abroad for radiation treatment given the stereotactic treatment we have developed and the fact that the neurosurgical unit in Beaumont has developed as well. I am not aware of that many cases. In fact, there are very few we would have to send abroad now for this sort of treatment.

Acting Chairman

Perhaps I could direct that question to Ms Prendergast. Is there any type of list? I know we may have to send someone abroad to the United States or the UK for certain procedures. Would you be aware of the numbers we have had to send for treatment for cancer?

Ms Prendergast

I would not at present. I am sure it is available in the Department on the hospital services side and I can refer back to you on that. I do not have any information in the finance unit on lists of people awaiting treatment abroad. However, I can get it from the Department, if we have it, and I shall send it on to you.

Acting Chairman

We would appreciate that. I had not been aware that we had sent people abroad for treatment for cancer, but I appreciate that you have more knowledge on that than I have.

Mr. Jermyn

To be clear, about 30 patients were sent abroad for radiation treatment for particular types of brain tumour. Now we can and will do a great deal of that ourselves in Ireland as we develop our techniques. It was about 30 a year or fewer and was more children based. That was purely for radiation treatment.

Acting Chairman

I thank Members for that examination and I thank the Chairman of the hospital and his colleagues for attending. We note the annual financial statements for 1995 and 1996 and the accounts of St. Luke's and St. Anne's hospital. Is that agreed? Agreed.

The witnesses withdrew.

Acting Chairman

The final item is we must agree the agenda for 1 June. It is suggested that we meet Galway city and county enterprise boards and Kerry, Kildare and Donegal county enterprise boards. Is that agreed? Agreed. We will now adjourn until 10 a.m. on Thursday, 1 June 2000.

The Committee adjourned at 12.25 p.m. until 10 a.m. on Thursday, 1 June 2000.